Chapter 15B-1 AE Administration Electronic OVERVIEW

Transcription

1 Chapter 15B-1 AE Administration Electronic OVERVIEW The GBAS specifications for loading HIPAA files contained in this appendix describe the specifications for loading EDI enrollment data into GBAS. The document contains a subset of the Health Care Administration Transaction Set (834) in version of the X12 ANSI standards. The information shows you where the GBAS proprietary information must be located in the 834 format as well as how it is used. Appendix B of AE-Admin Electronic Processing has been created to assist you in analyzing and troubleshooting problems that can occur in loading 834 X files from your various trading partners to meet GBAS file requirements. Using the information contained in this appendix also aids the FIS Client Services staff in effectively assisting you with any problems you are unable to resolve on your own.

2 PAGE 2 APPENDIX 15B-1. AE CHECKLIST 1. Review the Checklist items in Chapters 15. AE-Admin Electronic Processing. 2. Use the 834 X Implementation Guide available to you through the Internet in addition to Appendix B as your complete implementation documentation. 3. (See for a list of links to other informative HIPAA web sites.) GBAS V8.80 Administration June, 2016

3 APPENDIX 15B-1. AE PAGE 3 THINGS YOU NEED TO KNOW BEFORE BEGINNING How Appendix B-1 is Organized The chart in this Appendix covers the X12 loops that relate to the GBAS items that can be transmitted via the transaction set and their appropriate Segment, Element, Sequence, s, and values such as Case-Cert, Claimant, and individual benefits. There are items listed that can be considered optional and based on client-specific requirements. Submission of certain information via the 834 X is based on agreement with each of your trading partners. (See Chapter 15. AE-Admin Electronic Processing, section TPFM, for a discussion of the Trading Partner file.) June, 2016 GBAS V8.80 Administration

4 PAGE 4 APPENDIX 15B-1. AE 834 MAPPING TO GBAS FIELDS Interchange Control Header ISA Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definition and Interchange Control Header Interchange Control Header Function Group Header Function Group Header Transaction Set Header Beginning Segment ISA05 ISA06 ISA07 ISA08 Interchange ID Interchange Sender ID Interchange ID Interchange Receiver ID usage. Based upon trading partner agreements Based upon trading partner agreements Based upon trading partner agreements Based upon trading partner agreements ISA15 Usage Indicator This code indicates whether data enclosed by this interchange envelope is test or production P - Production Data T - Test Data GS Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definition and usage. GS08 Version/Release/ X220 Industry ST Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definition and usage. BGN Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definitions and usage. BGN01 00 Original Beginning Segment Transaction Set Policy BGN02 Transaction Set SPD:TRANS.SET.ID.CD$ BGN08 Action 2 - Change (Update) 4 - Verify RX Replace REF01 (REF01= 38 ) Master Policy Transaction Set Used to uniquely identify this occurrence of the transaction. For compliance purposes, if this segment is sent, then the TPFM/CC/Allow Trans Set Pol # Seg must be set to Y. GBAS V8.80 Administration June, 2016

5 APPENDIX 15B-1. AE PAGE 5 REF02 Master Policy Case used to select an individual in AI. File Effective Date (DTP=007) (DTP=090) (DTP=091) (DTP=303) (DTP=382) File Effective Date Report Start Date IND:CAS.NUM$ IBE:CAS.NUM$ CLM:CAS.NUM$ MBE:CAS.NUM$ Report End Date File Maintenance Date File Enrollment Date This segment is optional and dependent on how the Allow Trans Set Pol # in AE-EBE-TPFM is set. When received, the Case number specified is used for each member that is not superseded by a Policy segment. For compliance purposes, if the segment is sent, then the TPFM/CC/Allow File Eff Dates Seg 2 must be set to Y D8 - Date Expressed in Format CCYYMMDD For compliance purposes, if the segment is sent, then the TPFM/CC/Allow File Eff Dates Seg 2 must be set to Y D8 - Date Expressed in Format CCYYMMDD For compliance purposes, if the segment is sent, then the TPFM/CC/Allow File Eff Dates Seg 2 must be set to Y D8 - Date Expressed in Format CCYYMMDD For compliance purposes, if the segment is sent, then the TPFM/CC/Allow File Eff Dates Seg 2 must be set to Y Note: Certain operations require an as of date. For example, updating a member s claimant plan number must have an as of date in GBAS. The 303 date at the lowest applicable level encountered will be used. This date will be used for this purpose if an operation is performed that requires an as of date and no applicable lower level 303 date was received. D8 - Date Expressed in Format CCYYMMDD For compliance purposes, if the segment is sent, then the TPFM/CC/Allow File Eff Dates Seg 2 must be set to Y June, 2016 GBAS V8.80 Administration

6 PAGE 6 APPENDIX 15B-1. AE D8 - Date Expressed in Format CCYYMMDD Transaction Set Control Totals (DTP=388) QTY01 (QTY-DT) QTY02 File Payment Commencement Date Quantity Quantity For compliance purposes, if the segment is sent, then the TPFM/CC/Allow File Eff Dates Seg 2 must be set to Y D8 - Date Expressed in Format CCYYMMDD GBAS uses these new segments to confirm that a complete file is being processed. During compliance checking, prior to the start of processing data into GBAS, the member counts are determined and compared to the Control Totals received, if any. If any Control Totals do not match an error message(s) is issued and processing is aborted. 3 new Quantity s may now be received: DT - Dependent Total count of dependents (CLMs) in the EDI file. ET - Employee Total count of insured individuals (INDs) in the EDI file. TO Total count of all members in the file QTY01 (QTY-ET) QTY02 Quantity Quantity GBAS uses these new segments to confirm that a complete file is being processed. During compliance checking, prior to the start of processing data into GBAS, the member counts are determined and compared to the Control Totals received, if any. If any Control Totals do not match an error message(s) is issued and processing is aborted. 3 new Quantity s may now be received: DT - Dependent Total count of dependents (CLMs) in the EDI file. ET - Employee Total count of insured individuals (INDs) in the EDI file. TO Total count of all members in the file GBAS V8.80 Administration June, 2016

7 APPENDIX 15B-1. AE PAGE 7 QTY01 (QTY-TO) Quantity GBAS uses these new segments to confirm that a complete file is being processed. During compliance checking, prior to the start of processing data into GBAS, the member counts are determined and compared to the Control Totals received, if any. If any Control Totals do not match an error message(s) is issued and processing is aborted. 3 new Quantity s may now be received: DT - Dependent Total count of dependents (CLMs) in the EDI file. ET - Employee Total count of insured individuals (INDs) in the EDI file. TO Total count of all members in the file QTY02 Quantity Sponsor Name (1000A) Sponsor Name REF01 (REF01= P5 ) Entity P5 - Plan Sponsor N102 Plan Sponsor Name N103 N104 Sponsor SPN::SPON.ID$ Trading Partner ID in the 834 AE-EBE-TPFM File. 24 Employer s FI - Federal Taxpayer s ZZ - Mutually Defined Must exist in the Trading Partner definitions for the transaction set to be processed. Payer Name (1000B) Payer Name N101 Entity (N101=IN) N102 Insurer Name IN Insurer N assigned by the organization that is the ultimate destination of the transaction set FI - Federal Taxpayer's XV - Centers for Medicare and Medicaid Services Plan ID TPA/Broker Name (1000C) TPA/Broker Name N104 Insurer SPN:PAYOR.ID.NUM$ Payer ID in the 834 AE- EBE-TPFM File. Must exist in the Trading Partner definitions for the transaction set to be processed. N1 This Segment is not used by GBAS. June, 2016 GBAS V8.80 Administration

8 PAGE 8 APPENDIX 15B-1. AE TPA/Broker Account Info (1100C0 TPA/Broker Account Info ACT This Segment is not used by GBAS. Level Detail (2000) Level Detail INS01 Insured Indicator Y Indicates an individual N Indicates a claimant INS02 INS03 INS04 INS05 INS06 INS06-01 Individual Relationship Maintenance Type Maintenance Reason Benefit Status Medicare Plan Medicare Plan CLM::RELATION.$ IND::STATUS.REASON.C ODE$ CLM::STATUS.REASON. CODE$ (Relation to Insured) RelIns field in AI-CA. (Status Reason ) Rsn Cd field in AI and (Status Reason ) Sts Rsn field in AI-CA Must have a matching entry in the SYS MGR EDIT-EDI- EDIRELATE table to translate to the GBAS equivalent. This element functionality is controled by the TPFM/ Add/Change Flag 5 and TPFM/Change/Add Flag 6 fields in GBAS. 001 Means changing member information excluding terminating or reinstating, if the member does not exist and the change/add flag is set then the member will be added instead of signaling an error 021 Means adding a new member that might already be terminated, if the member already exists and the add/change flag is set then the member s information will be changed instead of signaling an error 024 Means terminating a member, if they are already terminated on a different date then it gives an error, to change a terminated member s termination date you must first reinstate them then terminate them on the new date. 025 Means reinstating a terminated member, a valid 303 date must be included to use as the reinstatement date, if the member is not terminated and the add/change flag is set then it will do a change instead of signaling an error 030 Can do any of the above within their rules based on the information received, the automatic reinstatement flag controls whether members are reinstated or an error is signaled during an audit only Used only when the UseStatReason field in SYS MGR CONTRL is set to Y. Must have a matching entry in the SYS MGR EDIT-EDI-EDISTATREA table to translate to GBAS equivalent. The value of C will include the member and the value in the COBRA report, that is all this is used for. This Segment is not used by GBAS. This Segment is not used by GBAS. GBAS V8.80 Administration June, 2016

9 APPENDIX 15B-1. AE PAGE 9 INS06-02 Eligibility This Segment is not used by GBAS. INS06-03 Eligibility This Segment is not used by GBAS. INS06-04 Eligibility This Segment is not used by GBAS. INS07 INS08 COBRA Qualifying Event Employment Status The 834 still does not support management of COBRA information in GBAS, any value here will include the member and the value in the COBRA report, that is all this is used for. INS09 Student Status CLM:: STUDENT.STATUS$ (Student Status) Student field in AI-CA. Converted to GBAS equivalent according to the following. 834 = GBAS value F (full-time) = S (full-time student) N (not a student) = N (not a full-time student P (part-time) = N (not a full-time student) INS10 INS11 INS12 Handicap Indicator Insured Individual Death Date CLM: DISABILITY.FLAG$ STUDENT.STATUS$ This element functionality is controled by the TPRM/ Set HC Student Stat to M 14, HC Student Minimum Age 15 and Set Disab Flag to HC Ind 16. If the TPFM Set Disab Flag to HC Ind 16 is set to Y then the CLM::DISABILITY.FLAG$ (AI/CA DisFlag 57 ) field will be set to the value received in the INS10 field. If the TPFM Set HC Student Stat to M 14 is set to Y and the member is a non-spouse dependent and the member s age is greater than the age specified in TPFM HC Student Minimum Age 15 and INS10 is set to Y then the member s student status will be set to M. That is the only way it can happen. This element is not used by GBAS INS13 Confident This element is not used by GBAS INS17 REF01 (REF01= 0F ) Birth Sequence CLM::BIRTH.SEQ$ AI.CA/XI/Brith Seg #233 In the absence of a member SSN or Alternate Key, the Date of Birth and Gender are used to identify members within an IND s family. If more than one member matches both values then if INS17 is supplied and populated in GBAS it is used to determine which member to match to. If it doesn t find the match then first name is tried. June, 2016 GBAS V8.80 Administration

10 PAGE 10 APPENDIX 15B-1. AE REF02 Policy REF01 (REF01= IL ) REF02 (REF01= IL ) REF01 (REF01=17) Insured Group or Policy (Client Reporting Category) IND::CERT.NUM$ IND::TIN.NUM$ IND::ALTERNATE.KEY$ IND::CAS.NUM$ IBE::CAS.NUM$ CLM::CAS.NUM$ MBE::CAS.NUM$ TPFM/FV/FIELD QUALIFIER (Cert ), Cert or (Social Security ) SocSec, SSN or (Alternate Key) AltKey fields in AI- CA Case used to select an individual in AI. Used to associate dependent claimants to their individual. Contains either a Cert, Social Security, or an Alternate Key based on the ID Type field setting in AE-EBE-TPFM File. When a Transaction Set Policy segment is received, this segment is optional and supercedes the value already received. When received, the case number specified is used for the member. The functionality of this element is controlled by the TPFM/ Allow Mem Clnt Rpt Cat Seg 3 field and the TPFM/FV in GBAS. REF02 REF01 (REF01= 23 ) (Client ) IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 TPFM/FV/FIELD QUALIFIER The functionality of this element is controlled by the TPFM/FV in GBAS. GBAS V8.80 Administration June, 2016

11 APPENDIX 15B-1. AE PAGE 11 REF02 IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 REF01 (REF01=3H) REF02 (Case ) TPFM/FV/FIELD QUALIFIER IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 The functionality of this element is controlled by the TPFM/FV in GBAS. June, 2016 GBAS V8.80 Administration

12 PAGE 12 APPENDIX 15B-1. AE REF01 (REF01=4A) TPFM/FV/FIELD QUALIFIER REF02 REF01 (REF01=6O) (Personal ) (Crossed Reference ) IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 TPFM/FV/FIELD QUALIFIER The functionality of this element is controlled by the TPFM/FV in GBAS. The functionality of this element is controlled by the TPFM/FV in GBAS. GBAS V8.80 Administration June, 2016

13 APPENDIX 15B-1. AE PAGE 13 REF02 IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 REF01 (REF01=ABB) REF02 (Personal ID ) TPFM/FV/FIELD QUALIFIER IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 The functionality of this element is controlled by the TPFM/FV in GBAS. Note that code ABB is represented by code AB to fit in the GBAS field. June, 2016 GBAS V8.80 Administration

14 PAGE 14 APPENDIX 15B-1. AE REF01 (REF01=D3) TPFM/FV/FIELD QUALIFIER REF02 REF01 (REF01=DX) REF02 (NCPDP Pharmacy ) (Department/ Agency) IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 TPFM/FV/FIELD QUALIFIER IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 The functionality of this element is controlled by the TPFM/FV in GBAS. The functionality of this element is controlled by the TPFM/FV in GBAS. GBAS V8.80 Administration June, 2016

15 APPENDIX 15B-1. AE PAGE 15 REF01 (REF01=F6) TPFM/FV/FIELD QUALIFIER REF02 REF01 (REF01=P5) REF02 (Health Insurance Claim HIC) (Position ) IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 TPFM/FV/FIELD QUALIFIER IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 The functionality of this element is controlled by the TPFM/FV in GBAS. The functionality of this element is controlled by the TPFM/FV in GBAS. June, 2016 GBAS V8.80 Administration

16 PAGE 16 APPENDIX 15B-1. AE REF01 (REF01=Q4) TPFM/FV/FIELD QUALIFIER REF02 REF01 (REF01=QQ) REF02 (Prior ) (Unit ) IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 TPFM/FV/FIELD QUALIFIER IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 The functionality of this element is controlled by the TPFM/FV in GBAS. The functionality of this element is controlled by the TPFM/FV in GBAS. GBAS V8.80 Administration June, 2016

17 APPENDIX 15B-1. AE PAGE 17 REF01 (REF01=ZZ) TPFM/FV/FIELD QUALIFIER Prior Coverage Months Prior Coverage Months Level Dates REF02 REF01 (REF01= QQ ) REF02 (= 050 ) (Mutually Defined) Prior Coverage Month Count Unit number Prior Coverage Month Count (Received) (Retirement) IND::Alternate Key CLM::Alternate Key IND:: Division IND Variant IND Division IND User Defined 9 IND User Defined 66 IND User Defined 67 CLM Claimant CLM Message 18 CLM User Defined 7 CLM User Defined 11 CLM User Defined 12 IND IndType IND Dep Cd 38 IND SpcDsc 50 CLM::COVG.CREDIT.MO NTHS% CLM::COVG.CREDIT.DA YS% (Coverage Credits Months) CovCrMM and (Coverage Credit Days) CovCrDD fields in AI-CA. The functionality of this element is controlled by the TPFM/FV in GBAS Segment ONLY The whole number portion of the value received is loaded into the Coverage Credit Months field. The Decimal portion of the value received is multiplied by ( / 12) to determine what the number of days in an average month would be and is loaded into the Coverage Credit Days field. Note that any partial day amount (decimal portion of the number) resulting from the computation is discarded. The integer portion of a number received is moved to the CovCrMM field and the decimal potion of the number, if received, is converted into days and moved to the CovCrDD field. This element is not used by GBAS. June, 2016 GBAS V8.80 Administration

18 PAGE 18 APPENDIX 15B-1. AE Level This element is not used by GBAS. Dates (= 286 ) (Retirement) (Retirement) (= 296 ) (= 297 ) (= 300 ) (= 301 ) (Return to Work) (Return to Work) (Date Last Worked) (Date Last Worked) (Enrollment Signature Date) (Enrollment Signature Date) (COBRA Qualifying Event) IND::APP.SIGNED.YYYY MMDD$ (Application Signature) App Sig field from AI. This element is not used by GBAS. This element is not used by GBAS. May be overwritten by receiving an Adjusted Hire or Rehire date. If this element is present it will place member data and value on the COBRA log. GBAS V8.80 Administration June, 2016

19 APPENDIX 15B-1. AE PAGE 19 (COBRA Qualifying Event) (= 303 ) (Maintenance Effective) (= 336 ) (= 337 ) (= 338 ) (Maintenance Effective) (Employment Begin) (Employment Begin) (Employment End) (Employment End) (Medicare Begin) CHG::EFF.YYYYMMDD$ BCH:: EFF.YYYYMMDD$ IND::EMPLOYMENT.YY YYMMDD$ Effect column in the field change function, FC and the Eff Date column of the benefit change, BC function. (Employment Date) Employ field in AI. When received, this date is used as the effective date of change for all activities. It is also used as the effective date for a reinstatement. This element is not used by GBAS. This element is not used by GBAS. June, 2016 GBAS V8.80 Administration

20 PAGE 20 APPENDIX 15B-1. AE (Medicare Begin) This element is not used by GBAS. (= 339 ) (Medicare End) (Medicare End) (= 340 ) (= 341 ) (COBRA Begin) (COBRA Begin) (COBRA End) If this element is present it will place member data and value on the COBRA log. If this element is present it will place member data and value on the COBRA log. (COBRA End) (= 350 ) (Education Begin) This element is not used by GBAS. GBAS V8.80 Administration June, 2016

21 APPENDIX 15B-1. AE PAGE 21 (Education Begin) (= 351 ) (Education End) This element is not used by GBAS. (Education End) (= 356 ) (Eligibility Begin) (Eligibility Begin) IND::EFF.YYYYMMDD$ CLM::EFF.YYYYMMDD$ (Effective Date) Pri Eff field in AI. (Effective Date) Effect field in AI-CA This date is used as the effective date for individuals and claimants. It is required during initial enrollment and causes an Effective Date Change operation if a different value is received later. (= 357 ) (Eligibility End) June, 2016 GBAS V8.80 Administration

22 PAGE 22 APPENDIX 15B-1. AE (Eligibility End) (= 383 ) (Adjusted Hire) IND::TERM.YYYYMMD D$ CLM::TERM.YYYYMMD D$ (Termination Date) Term field in AI. (Termination Date) Term field in AI-CA. This date is used as the termination date for individuals and claimants. It is required during termination. Once received, it cannot be changed except through reinstatement and retermination. (Adjusted Hire) IND::APP.SIGNED.YYYY MMDD$ (Application Signature) App Sig field from AI. May be overwritten by an Enrollment Signature or Rehire date. (= 385 (Credited Service Begin) This element is not used by GBAS. (Plan Participation Suspension) (= 386 (Credited Service End) This element is not used by GBAS. (Plan Participation Suspension) GBAS V8.80 Administration June, 2016

23 APPENDIX 15B-1. AE PAGE 23 (= 393 (Plan Participation Suspension) This element is not used by GBAS. (Plan Participation Suspension) (= 394 ) (Rehire) (Rehire) IND::APP.SIGNED.YYYY MMDD$ (Application Signature) App Sig field from AI. May be overwritten by an Enrollment Signature or Rehire date. (= 473 ) (Medicaid Begin) This element is not used by GBAS. (Medicaid Begin) June, 2016 GBAS V8.80 Administration

24 PAGE 24 APPENDIX 15B-1. AE (= 474 ) (Medicaid End) This element is not used by GBAS. (Medicaid End) Name (2100A) Name NM101 Entity 74 - Corrected Insured IL - Insured or NM102 Entity Type 1 - Person NM103 Last Name IND::LAST.NAME$ CLM::LAST.NAME$ (Last Name) Last Name field from AI and AI-CA. NM104 First Name IND::FIRST.NAME$ CLM::FIRST.NAME$ (First Name) First field from AI and AI-CA. NM105 Middle Name IND::MIDDLE.INITIAL$ CLM::MIDDLE.INITIAL$ (Middle Initial) MI field in AI and AI-CA. NM106 Name Prefix NM107 Name Suffix IND::SUFFIX.$ (Name Suffix) Sf field from AI and AI-CA. NM Social Security ZZ - Mutually Defined GBAS V8.80 Administration June, 2016

25 APPENDIX 15B-1. AE PAGE 25 NM109 (NM108= 34 ) IND::TIN.NUM$ CLM::TIN.NUM$ (Social Security ) SocSec field from AI and (Social Security ) SSN field from AI-CA. Communications s (2100A) Communications s PER01 Contact Function IP - Insured Party PER03 Communication AP - Alternate Telephone BN - Beeper CP - Cellular Phone EM - Electronic Mail EX - Telephone Extension FX - Facsimile HP - Home Phone TE - Telephone WP - Work Phone PER04 PER05 Communication (Home Phone ) Communication IND:: HOME.PHONE$ BUSINESS.PHONE$ ALTERNATE_PHONE::P HONE.NUM.14$ .ADDR$ CLM:: PHONE.NUM.14$ ALTERNATE_PHONE::P HONE.NUM.14$ .ADDR$. AP - Alternate Telephone BN - Beeper CP - Cellular Phone EM - Electronic Mail EX - Telephone Extension FX - Facsimile HP - Home Phone TE - Telephone WP - Work Phone June, 2016 GBAS V8.80 Administration

26 PAGE 26 APPENDIX 15B-1. AE PER06 Communication (Work Phone ) IND:: HOME.PHONE$ BUSINESS.PHONE$ ALTERNATE_PHONE::P HONE.NUM.14$ .ADDR$ CLM:: PHONE.NUM.14$ ALTERNATE_PHONE::P HONE.NUM.14$ .ADDR$ Residence Street Address PER07 PER08 N301 Communication Communication (Telephone) Address Line 1 IND:: HOME.PHONE$ BUSINESS.PHONE$ ALTERNATE_PHONE::P HONE.NUM.14$ .ADDR$ CLM:: PHONE.NUM.14$ ALTERNATE_PHONE::P HONE.NUM.14$ .ADDR$ IND::ADDR.LINE.1$ CLM::ADDR.LINE.1$ (Street Address Line 1) AddrLn1 field from AI-AM and Addr Ln 1 from AI- CA-AM. AP - Alternate Telephone BN - Beeper CP - Cellular Phone EM - Electronic Mail EX - Telephone Extension FX - Facsimile HP - Home Phone TE - Telephone WP - Work Phone TPFM/ Address Method 4 Claimant address is populated if it is different from the associated individual and the Use Claimant Addresses field in AE-EBE-TPFM has been set to Y. N302 Address Line 2 IND::ADDR.LINE.2$ CLM::ADDR.LINE.2$ (Street Address Line 2) AddrLn2 field from AI-AM and Addr Ln 2 from AI- CA-AM. TPFM/ Address Method 4 Claimant address is populated if it is different from the associated individual and the Use Claimant Addresses field in AE-EBE-TPFM has been set to Y. GBAS V8.80 Administration June, 2016

27 APPENDIX 15B-1. AE PAGE 27 Residence City, State, Zip N401 City Name IND::CITY.$ CLM::CITY.$ (City Name) City field in AI-AM and AI-CA-AM. TPFM/ Address Method 4 Claimant address is populated if it is different from the associated individual and the Use Claimant Addresses field in AE-EBE-TPFM has been set to Y. N402 State IND::STATE.$ CLM::STATE.$ (State ) St field in AI- AM and AI-CA-AM. TPFM/ Address Method 4 Claimant address is populated if it is different from the associated individual and the Use Claimant Addresses field in AE-EBE-TPFM has been set to Y. N403 Postal Zone or ZIP IND::ZIP.CODE$ CLM::ZIP.CODE$ (Zip ) Zip field from AI-AM and AI-CA-AM. TPFM/ Address Method 4 Claimant address is populated if it is different from the associated individual and the Use Claimant Addresses field in AE-EBE-TPFM has been set to Y. N404 Country N405 Location 60 - Area CY - County/Parish N406 (N405= CY ) Location (County/Parish) CLM::COUNTY.CODE$ (County ) County Cd field from AI-CA-XI. N407 Country Subdivision Demographics DMG01 Demographics DMG02 Birth Date IND::BIRTH.YYYYMMD D$ CLM::BIRTH.YYYYMMD D$ (Birth Date) Emp DOB field from AI and Birth field from AI-CA. Can be used for Claimant too. June, 2016 GBAS V8.80 Administration

28 PAGE 28 APPENDIX 15B-1. AE DMG03 Gender IND::SEX.$ CLM::SEX.$ (Gender) Sex field from AI and AI-CA. The value U (Unknown) listed in the manual is not a valid code in GBAS and is rejected if it is received. Can be used for Claimant too. DMG04 DMG05 DMG06 Marital Status Race or Ethnicity Citizenship Status IND::MARITAL.STATUS $ CLM::ETHNICITY.CODE $ (Marital Status) MarSts field from AI. (Race or Ethnicity) Ethnicity fields from AI- CA-XI. TPFM/CC/Allow Mem Marital Stat Cd 5 Converted to GBAS equivalent codes as listed. B (Registered Domestic Partner) = S (Single) I (Single) = S (Single) U (Unmarried) = S (Single) W (Widowed) = S (Single) M (Married) = M (Married) S (Separated) = M (Married) X (Legally Separated) = M (Married) D (Divorced) = D (Divorced) R (Unreported) = Blank (Unknown) TPFM/ CC/Allow Mem Ethnicity 6 A matching entry must exist in AS-ETHP. 7 - Not Provided 8 - Not Applicable A - Asian or Pacific Islander B - Black C - Caucasian D - Subcontinent Asian American E - Other Race or Ethnicity F - Asian Pacific American G - Native American H - Hispanic I - American Indian or Alaskan Native J - Native Hawaiian N - Black (Non-Hispanic) O - White (Non-Hispanic) P - Pacific Islander Z - Mutually Defined TPFM/CC/Allow Mem Citizen Status U.S. Citizen 2 - Non-Resident Alien 3 - Resident Alien 4 - Illegal Alien 5 - Alien 6 - U.S. Citizen - Non-Resident 7 - U.S. Citizen - Resident GBAS V8.80 Administration June, 2016

29 APPENDIX 15B-1. AE PAGE 29 DMG10 Race Or Ethnicity Collection This element is not used by GBAS DMG11 Ethnic Industry This element is not used by GBAS Employment Class EC Employment Class This segment is not used by GBAS Income ICM01 Frequency TPFM/ CC/Allow Income Seg 8 1 Weekly 2 Biweekly 3 Semimonthly 4 Monthly 6 Daily 7 Annual 8 Two Calendar Months 9 Lump-Sum Separation Allowance B Year-to-Date C Single H Hourly Q Quarterly S Semiannual U Unknown ICM02 Wage Amount IND::SALARY.AMT (Salary) Salary field from AI. TPFM/ CC/Allow Income Seg 8 ICM03 ICM04 ICM05 Work Hours Count Location Salary Grade TPFM/CC/Allow Work Hours Count 9 TPFM/CC/Allow Work Loc ID 10 TPFM/CC/Allow Work Salary Grade 11 June, 2016 GBAS V8.80 Administration

30 PAGE 30 APPENDIX 15B-1. AE Policy AMT TPFM/CC/Allow Policy Amounts Seg 12 Amounts Health Info HLT This element is not used by GBAS. Language LUI01 TPFM/CC/Allow Language Seg 13 Language LUI02 Language CLM::LANGUAGE():: LANGUAGE.CODE$ (Language) Language1 and Language2 fields from AI- CA-XI. The value in this field is used only if no value is received in LUI03. A matching entry must exist in AS-LANGP. LUI03 Language Description CLM::LANGUAGE():: LANGUAGE.CODE$ (Language) Language1 and Language2 fields from AI- CA-XI. A matching entry must exist in AS-LANGP. LUI04 Language Indicator 5 Language Reading 6 Language Writing 7 Language Speaking 8 Native Language Incorrect Name (2100B) Incorrect Name NM101 Entity 70 Prior Incorrect Insured NM102 Entity Type 1 Person NM103 Prior Incorrect Insured Last Name IND::LAST.NAME$ CLM::LAST.NAME$ (Last Name) Last Name field from AI and AI-CA. Used to identify an existing individual or claimant. GBAS V8.80 Administration June, 2016

31 APPENDIX 15B-1. AE PAGE 31 NM104 Prior Incorrect Insured First Name IND::FIRST.NAME$ CLM::FIRST.NAME$ (First Name) First Name field from AI and AI-CA. Used to identify an existing individual or claimant. NM105 Prior Incorrect Insured Middle Name IND::MIDDLE.INITIAL$ CLM::MIDDLE.INITIAL$ (Middle Initial) MI field from AI and AI-CA. Used to identify an existing individual or claimant. NM106 Prior Incorrect Insured Name Prefix NM107 Prior Incorrect Name Suffix IND::SUFFIX.$ CLM::SUFFIX.$ (Suffix) Sf field from AI and AI-CA. Used to identify an existing individual or claimant. NM108 Qualifer 34 Social Security ZZ Mutually Defined NM109 (NM108= 34 ) Prior Incorrect IND::TIN.NUM$ CLM::TIN.NUM$ (Social Security ) SocSec field from AI and SSN field from AI-CA. Used to identify an existing individual or claimant. Incorrect Demographics DMG01 DMG02 Prior Incorrect Insured Birth Date IND::BIRTH.YYYYMMD D$ CLM::BIRTH.YYYYMMD D$ (Birth Date) Emp DOB field from AI and Birth field from AI-CA. Used to identify an existing individual or claimant. DMG03 Prior Incorrect Insured Gender IND::SEX.$ CLM::SEX.$ (Gender) Sex field from AI and AI-CA. Used to identify an existing individual or claimant. June, 2016 GBAS V8.80 Administration

32 PAGE 32 APPENDIX 15B-1. AE Mailing Mailing NM101 Entity Where: Address (2100C) Address On the AI/AM or AI/CA/AM screens: Address Line 1 to Address Line 1 Address Line 2 to Address Line 2 City to City State to State Zip to Zip When: From TPFM help for the Address Method 4 field: Enter the method for loading the individual and claimant address into GBAS. 1 - Use residence address for individual only. Claimant ignored. 2 - Use residence address for individual. Load claimant address only if different. 3 - Use mailing address for individual and claimant if received. Otherwise, use residence address for both. 4 - Use mailing address for individual if received. Otherwise, use residence address for individual and claimant. NM102 Entity Type 1 Person Mail Street Address N301 Address Line AI/CA/AM fields Where: On the AI/AM or AI/CA/AM screens: Address Line 1 to Address Line 1 Address Line 2 to Address Line 2 City to City State to State Zip to Zip When: From TPFM help for the Address Method 4 field: Enter the method for loading the individual and claimant address into GBAS. 1 - Use residence address for individual only. Claimant ignored. 2 - Use residence address for individual. Load claimant address only if different. 3 - Use mailing address for individual and claimant if received. Otherwise, use residence address for both. 4 - Use mailing address for individual if received. Otherwise, use residence address for individual and claimant. GBAS V8.80 Administration June, 2016

33 APPENDIX 15B-1. AE PAGE 33 N301 Address Line AI/CA/AM fields Where: On the AI/AM or AI/CA/AM screens: Address Line 1 to Address Line 1 Address Line 2 to Address Line 2 City to City State to State Zip to Zip When: From TPFM help for the Address Method 4 field: Enter the method for loading the individual and claimant address into GBAS. 1 - Use residence address for individual only. Claimant ignored. 2 - Use residence address for individual. Load claimant address only if different. 3 - Use mailing address for individual and claimant if received. Otherwise, use residence address for both. 4 - Use mailing address for individual if received. Otherwise, use residence address for individual and Mail City State Zip N401 City Name AI/CA/AM fields claimant. Where: On the AI/AM or AI/CA/AM screens: Address Line 1 to Address Line 1 Address Line 2 to Address Line 2 City to City State to State Zip to Zip When: From TPFM help for the Address Method 4 field: Enter the method for loading the individual and claimant address into GBAS. 1 - Use residence address for individual only. Claimant ignored. 2 - Use residence address for individual. Load claimant address only if different. 3 - Use mailing address for individual and claimant if received. Otherwise, use residence address for both. 4 - Use mailing address for individual if received. Otherwise, use residence address for individual and claimant. June, 2016 GBAS V8.80 Administration

34 PAGE 34 APPENDIX 15B-1. AE N402 State AI/CA/AM fields See above Where: On the AI/AM or AI/CA/AM screens: Address Line 1 to Address Line 1 Address Line 2 to Address Line 2 City to City State to State Zip to Zip When: From TPFM help for the Address Method 4 field: Enter the method for loading the individual and claimant address into GBAS. 1 - Use residence address for individual only. Claimant ignored. 2 - Use residence address for individual. Load claimant address only if different. 3 - Use mailing address for individual and claimant if received. Otherwise, use residence address for both. 4 - Use mailing address for individual if received. Otherwise, use residence address for individual and claimant. N403 Postal Zone or Zip AI/CA/AM fields Where: On the AI/AM or AI/CA/AM screens: Address Line 1 to Address Line 1 Address Line 2 to Address Line 2 City to City State to State Zip to Zip When: From TPFM help for the Address Method 4 field: Enter the method for loading the individual and claimant address into GBAS. 1 - Use residence address for individual only. Claimant ignored. 2 - Use residence address for individual. Load claimant address only if different. 3 - Use mailing address for individual and claimant if received. Otherwise, use residence address for both. 4 - Use mailing address for individual if received. Otherwise, use residence address for individual and claimant. N404 Country This element is not used by GBAS. Employer (2100D) Employer NM1 Entity Segment Not used by GBAS GBAS V8.80 Administration June, 2016

35 APPENDIX 15B-1. AE PAGE 35 Employer Communication s PER Contact Function Segment Not used by GBAS Employer Street Address N3 Address Line Segment Not Used by GBAS Employer City State Zip N4 City Name Segment Not Used by GBAS School (2100E) School NM1 Entity Segment Not Used by GBAS School Communication s PER Contact Function Segment Not Used by GBAS School Street Address N3 School Address Line Segment Not Used by GBAS School City State Zip N4 School City Name Segment Not Used by GBAS Custodial Parent (2100F) Custodial Parent NM1 Segment Not Used by GBAS Custodial Parent Communication s PER Segment Not Used by GBAS Custodial Parent Street Address N3 Segment Not Used by GBAS June, 2016 GBAS V8.80 Administration

36 PAGE 36 APPENDIX 15B-1. AE Custodial Parent N4 Segment Not Used by GBAS City State Zip Responsible Person (2100G) Responsible Person NM1 Segment Not Used by GBAS Responsible Person Communication s PER Segment Not Used by GBAS Drop Off Location (2100G) Responsible Person Street Address Responsible Person City State Zip Drop Off Location Drop Off Location Street Address Drop Off Location City, State, Zip N3 Segment Not Used by GBAS N4 Segment Not Used by GBAS NM1 Segment Not Used by GBAS N3 Segment Not Used by GBAS N4 Segment Not Used by GBAS Disability Information (2200) Disability Information DSB01 Disability Type Segment Not Used by GBAS Disability Eligibility Dates (=360) Disability Begin Segment Not Used by GBAS Disability Eligibility Dates (=361) Disability End Segment Not Used by GBAS GBAS V8.80 Administration June, 2016

37 APPENDIX 15B-1. AE PAGE 37 Health Coverage Health Coverage HD01 Maintenance 032 is not supported. (2300) Type Basically the processing logic only allows two types of operations for benefits: Adds and Terms. 001, 021, 025, 026, and 030 are Add operations. If a Benefit End (349) Date is included then it will also be applied by terming the benefit being added. If no Benefit Begin (348) Date is included it will use the Maintenance Effective (303) Date if one is included, otherwise, the operation will signal an error. 002 and 024 are term operations. If a Benefit Begin (348) Date is included then it will also be applied by adding the benefit being termed. If no Benefit End (349) Date is included it will use the Maintenance Effective (303) Date if one is included, otherwise, the operation will signal an error. When applying a benefit time period, the program will create as many benefit iterations as needed to insure that the benefit is active from the Benefit Begin (348) Date to the Benefit End (349) Date regardless of how many gaps need to be filled in. HD02 HD03 Insurance Line IBE::BENEFIT.CODE$ (Benefit ) Benefit field from AI-BM. The value received combined with the Plan Coverage Description and Coverage Level must have a matching entry in AE-EBE-BDFM for conversion to GBAS Benefit s. HD04 Plan Coverage Description IBE::BENEFIT.CODE$ (Benefit ) Benefit field from AI-BM. The value received combined with the Insurance Line and Coverage Level must have a matching entry in AE-EBE- BDFM for conversion to GBAS Benefit s. HD05 Coverage Level IBE::BENEFIT.CODE$ (Benefit ) Benefit field from AI-BM. The value received combined with the Insurance Line and Plan Coverage Description must have a matching entry in AE- EBE-BDFM for conversion to GBAS Benefit s. June, 2016 GBAS V8.80 Administration

38 PAGE 38 APPENDIX 15B-1. AE HD09 Late Enrollee Indicator A new Late Enrollment Indicator may now be received: Y - Yes N - No A new parameter file named EDILOCCAT.DAT in your GPUSER directory will now be used to identify which Insurance Line s are medical. It should contain the following 3 comma separated parameters on each line within it: EDI Insurance Line EDI Insurance LIne Description GBAS Line Of Coverage Category ("MED","DEN", "VIS") When matching entries in the parameter file the first match encountered will be used. If parameter 3 of the line matched is "MED" and the HD contains the most recent Benefit Begin Date received of the matched medical HDs, then the value will be "flipped" and applied to the On Time Enrollment Indicator in GBAS. No Late Enrollment Indicator received, non-medical matched HDs, no match found HDs, or no parameter file found will cause the default behavior to occur. Note that the default behavior has been modified to implement use of CONTRL Setting 101 "ClmOTEnrolDef" in the following manner: E - Default to N if the effective date of the claimant does not match the case and default to Y if the effective date of the claimant does match the case. Y - Always default to Y. B - Always default to Y. (User cannot be prompted during Inbound 834 processing.) Health Coverage Dates (= 300 ) Date/Time This element is not used by GBAS Health Coverage Dates (= 300 ) Coverage (Enrollment Signature Date) This element is not used by GBAS GBAS V8.80 Administration June, 2016

39 APPENDIX 15B-1. AE PAGE 39 Health Coverage Date/Time Dates (= 303 ) Health Coverage Dates (= 303 ) Coverage (Maintenance Effective) IBE::EFF.YYYYMMDD$ IBE::TERMYYYYMMDD $ (Effective Date) Effect field and (Termination Date) Term fields in AI-BM. When received, this value is used as the effective date for all benefit changes. When a benefit addition request is received and no benefit begin date is received, this value is used as the effective date. When a benefit termination request is received and no benefit end date is received, this value is used as the termination date. This occurs most often during Audit or Compare operations. Health Coverage Dates (= 343 ) Date/Time This element is not used by GBAS Health Coverage Dates (= 343 ) Coverage (Premium Paid to Date End) This element is not used by GBAS (= 348 ) Date/Time (= 348 ) Coverage (Benefit Begin) IBE::EFF.YYYYMMDD$ (Effective Date) Effect field in AI-BM. (= 349 ) Date/Time June, 2016 GBAS V8.80 Administration

40 PAGE 40 APPENDIX 15B-1. AE Coverage IBE::TERM.YYYYMMDD (Termination Date) Term (= 349 (Benefit End) $ field in AI-BM (= 543 ) Date/Time This element is not used by GBAS (= 543 Coverage (Last Premium Paid Date) (= 695 ) Date/Time This element is not used by GBAS (= 695 ) Coverage (Previous ) Health Coverage Policy AMT Health Coverage Policy REF Prior Coverage Months REF01 (REF01=QQ) REF02 Reference Prior Coverage Month Count This segment now resides within the Health Coverage loop. It is built for Coverage Credit Months and Coverage Credit Days using the same logic that was used at its previous location. However, it will only be sent if the Insurance Line is identified as medical using the same logic as described above for the Late Enrollment Indicator on the HD segment. GBAS V8.80 Administration June, 2016

41 APPENDIX 15B-1. AE PAGE 41 Card IDC01 Plan Coverage Description This value determines the format to use in an ID Card generation request. A value of 0 defaults to the format listed on the benefit code to which the request is associated. IDC02 Card Type D Dental Insurance H Health Insurance P Prescription Drug Service Drug Insurance IDC03 Card Count Provider Information (2310) Provider Information IDC04 Action This value defines if they are new or replacement cards. The values received are translated according to the following. 1 (Add) = N (New) 2 (Change) = R Replace) RX (Replace) = R (Replace) The program builds an INDLOAD ID Card Request from the information received. This request includes: Case Action Date ID Format loaded with the unchanged IDC01 received. ID Prompt Flag as follows: If IDC04 = blank or 1 then N Else R For additional information on this you ll have to ask Doug since I don t know anything about it and to the best of my knowledge none of our clients use this feature in the 834. LX01 Assigned Provider Name NM101 Entity Type If the NM101 is P3 and at least one benefit being managed by the HD specification is a Level Benefit and a Managed Care Plan is set up that allows specification of PCPs on the MBE then: All information received is handed to a matching routine to find a provider to load onto the benefit code specification in GBAS. HIPAA limitations about handing in ID values makes this feature virtually useless. June, 2016 GBAS V8.80 Administration

42 PAGE 42 APPENDIX 15B-1. AE NM102 Entity Type 1 Person 2 Non-Person Entity NM103 Provider Last or Organization Name NM104 Provider First Name NM105 Provider Middle Name NM106 Provider Name Prefix NM107 Provider Name Suffix NM Social Security FI Federal Taxpayer s SV Service Provider XX Health Care Financing Administration National Provider NM109 Provider NM110 Entity Relationship 25 Established Patient 26 Not Established Patient 72 Unknown Provider Address N3 Provider Address Line Segment not used by GBAS Provider City State Zip N4 Provider City Name Segment not used by GBAS Provider Communication s PER Contact Function Segment not used by GBAS PCP Change Reason PLA01 Action The Provider Effect Date is used in applying the PCP specification listed above if a match is made. 2 Change (Update) GBAS V8.80 Administration June, 2016

43 APPENDIX 15B-1. AE PAGE 43 PLA02 Entity 1P Provider PLA03 Provider Effect Date Coordination of Benefits (2320) Coordination of Benefits PLA05 COB01 COB02 Maintenance Reason Payer Responsibility Sequence Insured Group or Policy CLM::OTHER_INSURAN CE()::COB.CODE$ CLM::OTHER_INSURAN CE()::COB.POLICY.NUM $ (Status ) field in AI-CA-OC. (Policy ) POL field in AI-CA-OC. 14 Voluntary Withdrawal 22 Plan Change 46 Current Customer Information File in Error AA Dissatisfaction with Office Staff AB Dissatisfaction with Medical Care/Services Rendered AC Inconvenient Office Location AD Dissatisfaction with Office Hours AE Unable to Schedule Appointments in a Timely Manner AF Dissatisfaction with Physician s Referral Policy AG Less Respect and Attention Time Given than to Other Patients AH Patient Moved to a New Location AI No Reason Given AJ Appointment Times not Met in a Timely Manner Medical, Dental, or Vision determined by Coverage Line of the associated Health Coverage segment. The value received is translated according to the following. P (Primary) = S (Other carrier is primary) S (secondary) = P (Other carrier is secondary) T (Tertiary) = P (Other carrier is secondary) U (Unknown) = P (Other carrier secondary) Medical, Dental, Vision is determined by the Coverage Line in the associated Health Coverage segment. Additional Coordination of Benefits s COB03 Coordination of Benefits Medical, Dental, Vision is determined by the Coverage Line in the associated Health Coverage segment. The action taken is determined according to the following. 1 (Coordination of Benefits) = Set the current values in GBAS 5 (Unknown) = Ignore the specification 6 (No Coordination of Benefits) = Erase the current values in GBAS. REF Segment not used by GBAS June, 2016 GBAS V8.80 Administration

44 PAGE 44 APPENDIX 15B-1. AE Other Insurance N101 Entity IN Insurer Company Name N102 Insurer Name CLM::OTHER_INSURAN CE():: COMPANY::NAME.$ (Company Name) Comp field in AI-CA-OC. Medical, Dental, Vision is determined by the Coverage Line in the associated Health Coverage segment. If a unique and exact match has been defined in AS-COBP, the associated Carrier is loaded. N103 FI Federal Taxpayer s NI National Association of Insurance Commissioners (NAIC) XV Health Care Financing Administration National PlanID N104 Insured Group or Policy CLM::OTHER_INSURAN CE():: COMPANY::NAME.$ CLM::OTHER_INSURAN CE()::COB.CAR.CODE$ (Company Name) Comp field in AI-CA-OC Medical, Dental, Vision is determined by the Coverage Line in the associated Health Coverage segment. This value is used only when no Insured Name is received. If a unique and exact match has been defined in AS-COBP, the associated Carrier is loaded. Coordination of Benefits Eligibility Dates (= 344 ) Date/Time (= 344 ) Coordination of Benefits Date (Coordination of Benefits Begin) CLM::OTHR_INSURANC E():: EFF.DATE.YYYYMMDD $ The (Effective Date) Eff field in AI-CA-OC. Medical, Dental, Vision is determined by the Coverage Line in the associated Health Coverage segment. (= 345 ) Date/Time GBAS V8.80 Administration June, 2016

45 APPENDIX 15B-1. AE PAGE 45 The (Termination Date) (= 345 ) Trm field in AI-CA-OC. Coordination of Benefits Date (Coordination of Benefits End) CLM::OTHR_INSURANC E():: TERM.DATE.YYYYMMD D$ Medical, Dental, Vision is determined by the Coverage Line in the associated Health Coverage segment. Coordination of Benefits Related Entity (2330) NM1 Coordination of Benefits Related Entity This new loop and segment are used to replace the old Other Insurance Company Name segment. It is processed in exactly the same manner loading name when received and appropriate. N3 Coordination of Benefits Related Entity Address Segment not used by GBAS N4 Coordination of Benefits Other Insurance Company City State Zip Segment not used by GBAS Additional Report Categories PER LS Administrative Communications Contact Loop Segment not used by GBAS Segment not used by GBAS Reporting Categories (2710) LX Reporting Categories Segment not used by GBAS Reporting Category (2750) N1 Reporting Category Segment not used by GBAS REF Reporting Category Reference Segment not used by GBAS DTP Reporting Category Date Segment not used by GBAS June, 2016 GBAS V8.80 Administration

46 PAGE 46 APPENDIX 15B-1. AE Additional Reporting Categories Loop Termination LE Segment not used by GBAS Transaction Set Trailer SE Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definition and usage. Functional Group Trailer GE Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definition and usage. Interchange Control Trailer IES Refer to the National Electronic Data Interchange Transaction Set Implementation Guide Benefit Enrollment & Maintenance to definition of complete element definition and usage. GBAS V8.80 Administration June, 2016